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Konishi T, Kawakami R, Vozenilek AE, Ghosh SKB, Xu W, Grogan A, Shah P, Tanaka T, Sekimoto T, Shiraki T, Kawai K, Sato Y, Mori M, Sakamoto A, Hisadome H, Ashida K, Bellissard A, Williams D, Dryanovski D, Kutys R, Cheng Q, Romero M, Chahal D, Virmani R, Finn AV. Mechanisms of Medial Wall Thinning in Chronic Total Occlusion. JACC Cardiovasc Interv 2024; 17:1719-1728. [PMID: 38970581 DOI: 10.1016/j.jcin.2024.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/25/2024] [Accepted: 05/07/2024] [Indexed: 07/08/2024]
Abstract
BACKGROUND The success rate of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) is lower and the risk for complications higher compared with other non-CTO PCI. Although interventionalists focus on intimal plaque characteristics, the coronary media is an important (especially for techniques involving antegrade dissection and re-entry) but poorly understood structure in CTO PCI. OBJECTIVES The aim of the present study was to investigate coronary medial wall thinning in CTO lesions and determine how this thinning might affect CTO PCI. METHODS A total of 2,586 sections were investigated, from arteries with evidence of CTO from 54 subjects (1,383 sections) and arteries without evidence of CTO from 54 subjects with non-coronary-related deaths (1,203 sections) after matching for age, gender, body weight, and body height. RESULTS The medial thickness in subjects with CTO was lower than that in those with non-coronary-related death (P < 0.001). In subjects with CTO, CTO lesions had thinner medial walls compared with those with lower luminal narrowing (P < 0.001). At the CTO distal segments, the 6- to 12-mm distal segment from the distal end of the CTO had significantly less luminal narrowing (P < 0.001), and similar medial thickness, compared with the distal end of the CTO. Immunohistochemical analysis revealed that short-duration CTO had more cleaved caspase-3-positive cells in media and had significantly more CD3+, CD4+, CD8+, and CD4+CD28null T cells compared with long-duration CTO. CONCLUSIONS CTO lesions demonstrated coronary medial thinning compared with non-CTO lesions. Further investigation of the cause-and-effect relationship among inflammation, apoptosis, and coronary medial wall thinning is warranted in future mechanistic studies.
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Affiliation(s)
- Takao Konishi
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, Maryland, USA; Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Rika Kawakami
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, Maryland, USA
| | - Aimee E Vozenilek
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, Maryland, USA
| | - Saikat Kumar B Ghosh
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, Maryland, USA
| | - Weili Xu
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, Maryland, USA
| | - Alyssa Grogan
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, Maryland, USA
| | - Palak Shah
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, Maryland, USA
| | - Takamasa Tanaka
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, Maryland, USA
| | - Teruo Sekimoto
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, Maryland, USA
| | - Tatsuya Shiraki
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, Maryland, USA
| | - Kenji Kawai
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, Maryland, USA
| | - Yu Sato
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, Maryland, USA
| | - Masayuki Mori
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, Maryland, USA
| | - Atsushi Sakamoto
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, Maryland, USA
| | | | - Kazuhiro Ashida
- Cardiovascular Center, Seirei Yokohama Hospital, Yokohama, Japan
| | - Arielle Bellissard
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, Maryland, USA
| | - Desiree Williams
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, Maryland, USA
| | - Dilyan Dryanovski
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, Maryland, USA
| | - Robert Kutys
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, Maryland, USA
| | - Qi Cheng
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, Maryland, USA
| | - Maria Romero
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, Maryland, USA
| | - Diljon Chahal
- School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Renu Virmani
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, Maryland, USA
| | - Aloke V Finn
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, Maryland, USA; School of Medicine, University of Maryland, Baltimore, Maryland, USA.
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Rubini Gimenez M, Scheller B, Farah A, Ohlow MA, Mangner N, Weilenmann D, Wöhrle J, Cuculi F, Leibundgut G, Möbius-Winkler S, Cattaneo M, Gilgen N, Kaiser C, Jeger RV. Sex-specific inequalities in the use of drug-coated balloons for small coronary artery disease: a report from the BASKET-SMALL 2 trial. Clin Res Cardiol 2024; 113:959-966. [PMID: 37495797 PMCID: PMC11219376 DOI: 10.1007/s00392-023-02249-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 06/19/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND AND OBJECTIVES Recent data have established non-inferiority of drug-coated balloons (DCB) compared to drug-eluting stents (DES) for treatment of small-vessel coronary artery disease. Since coronary vessels in women might have anatomical and pathophysiological particularities, the safety of the DCB strategy among women compared to men needs to be assessed in more detail. METHODS In BASKET-SMALL 2, patients with de novo lesions in coronary vessels < 3 mm and an indication for percutaneous coronary intervention were randomly allocated (1:1) to DCB vs. DES after successful lesion preparation. The primary objective of the randomized trial was to establish non-inferiority of DCB vs. DES regarding major adverse cardiac events (MACE; i.e., cardiac death, non-fatal myocardial infarction, and target vessel revascularization) after 12 months. The aim of the current sub-analysis is to evaluate whether the DCB strategy is equally safe among women and men after 12 and 36 months. RESULTS Among 758 randomized patients, 382 were assigned to DCB (23% women) and 376 to DES (30% women). In general, women were older, had more often diabetes mellitus and renal insufficiency, and presented more often with an acute coronary syndrome, whereas men were more often smokers, had multivessel disease and a previous history of acute myocardial infarction, and received a treatment with a statin. After 3 years, the primary clinical end point was not significantly different between groups (13% women vs. 16% men, HR 0.82; 95% CI 0.52-1.30; p = 0.40). There was no interaction between sex and coronary intervention strategy regarding MACE at 36 months (10% women vs. 16% men in DCB, 16% women vs. 15% men in DES; pinteraction = 0.31). CONCLUSION In small native coronary artery disease, there was no statistically significant effect of sex on the difference between DCB and DES regarding MACE up to 36 months. CLINICAL TRIAL REGISTRATION URL: http://www. CLINICALTRIALS gov . Unique identifier: NCT01574534.
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Affiliation(s)
- Maria Rubini Gimenez
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Bruno Scheller
- Clinical and Experimental Interventional Cardiology, Saarland University, Homburg/Saar, Germany
| | - Ahmed Farah
- Department of Cardiology Central Clinic Bad Berka, Bad Berka, Germany
| | | | - Norman Mangner
- Department of Internal Medicine and Cardiology, Herzzentrum Dresden, Technische Universitaet Dresden, Dresden, Germany
| | - Daniel Weilenmann
- Department of Cardiology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Jochen Wöhrle
- Department of Cardiology, University Hospital Ulm, Ulm, Germany
| | - Florim Cuculi
- Department of Cardiology, Cantonal Hospital Luzern, Luzern, Switzerland
| | - Gregor Leibundgut
- Department of Cardiology, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Sven Möbius-Winkler
- Department of Cardiology, Friedrich-Schiller-University of Jena, Jena, Germany
| | - Marco Cattaneo
- Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Nicole Gilgen
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Christoph Kaiser
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Raban V Jeger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel and University of Basel, Basel, Switzerland.
- Department of Cardiology, Triemli Hospital, Zurich, Switzerland.
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3
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Kuno T, Ohata T, Nakamaru R, Sawano M, Kodaira M, Numasawa Y, Ueda I, Suzuki M, Noma S, Fukuda K, Kohsaka S. Long-term outcomes of periprocedural coronary dissection and perforation for patients undergoing percutaneous coronary intervention in a Japanese multicenter registry. Sci Rep 2023; 13:20318. [PMID: 37985895 PMCID: PMC10662469 DOI: 10.1038/s41598-023-47444-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 11/14/2023] [Indexed: 11/22/2023] Open
Abstract
Long-term outcomes of iatrogenic coronary dissection and perforation in patients undergoing percutaneous coronary intervention (PCI) remains under-investigated. We analyzed 8,721 consecutive patients discharged after PCI between 2008 and 2019 from Keio Cardiovascular (KiCS) PCI multicenter prospective registry in the Tokyo metropolitan area. Significant coronary dissection was defined as persistent contrast medium extravasation or spiral or persistent filling defects with complete distal and impaired flow. The primary outcome was a composite of all-cause death, acute coronary syndrome, heart failure, bleeding, stroke requiring admission, and coronary artery bypass grafting two years after discharge. We used a multivariable Cox hazard regression model to assess the effects of these complications. Among the patients, 68 (0.78%) had significant coronary dissections, and 61 (0.70%) had coronary perforations at the index PCI. Patients with significant coronary dissection had higher rates of the primary endpoint and heart failure than those without (25.0% versus 14.3%, P = 0.02; 10.3% versus 4.2%, P = 0.03); there were no significant differences in the primary outcomes between the patients with and without coronary perforation (i.e., primary outcome: 8.2% versus 14.5%, P = 0.23) at the two-year follow-up. After adjustments, patients with coronary dissection had a significantly higher rate of the primary endpoint than those without (HR 1.70, 95% CI 1.02-2.84; P = 0.04), but there was no significant difference in the primary endpoint between the patients with and without coronary perforation (HR 0.51, 95% CI 0.21-1.23; P = 0.13). For patients undergoing PCI, significant coronary dissection was associated with poor long-term outcomes, including heart failure readmission.
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Affiliation(s)
- Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210Th St, New York, NY, 10467-2401, USA.
- Division of Cardiology, Jacobi Medical Center, New York, USA.
| | - Takanori Ohata
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Ryo Nakamaru
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
- Department of Healthcare Quality Assessment, The University of Tokyo, Tokyo, Japan
| | - Mitsuaki Sawano
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, USA
| | - Masaki Kodaira
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Yohei Numasawa
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Ashikaga, Japan
| | - Ikuko Ueda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Masahiro Suzuki
- Department of Cardiology, National Hospital Organization Saitama Hospital, Wako, Japan
| | - Shigetaka Noma
- Department of Cardiology, Saiseikai Utsunomiya Hospital, Utsunomiya, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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4
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Al Mawed M, Vlachojannis M, Pula A, Gielen S. Delayed coronary perforation four days after percutaneous coronary intervention with subsequent cardiac tamponade: A case report. Catheter Cardiovasc Interv 2023; 102:1061-1065. [PMID: 37855161 DOI: 10.1002/ccd.30861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 08/27/2023] [Accepted: 10/05/2023] [Indexed: 10/20/2023]
Abstract
Coronary artery perforation (CAP) is a rare but lethal complication of percutaneous coronary interventions (PCIs), and its incidence has been increasing with advances in PCI techniques. Delayed CAP presents a highly challenging complication, as it occurs 30 min-9 days after intervention, making subsequent diagnosis and treatment difficult. We present the case of a 63-year-old male patient who underwent PCI for an obtuse marginalis II because of posterior wall myocardial infarction. Following 4 days of uneventful postoperative stay, the patient developed angina pectoris and hypotension 4 h after reinitiation of anticoagulant therapy with edoxaban. Angiography revealed distal vessel perforation from a side branch of the obtuse marginalis II. The vessel was occluded using autologous fat embolization via a microcatheter, resulting in complete sealing of the perforation. After discharge, 4 weeks after the infarction, the patient started rehabilitation therapy. Distal vessel perforations are typically caused by wire damage. In our case, we also suspected distal wire perforation, which was initially not recognized possibly due to distal occlusion through the thrombotic material. The temporal correlation between the re-initiation of anticoagulant therapy and the occurrence of cardiac tamponade suggests that the thrombotic material was resolved due to the former. The management of delayed CAP does not differ from that of CAP; thus, this rare complication should be considered even days after PCI as it could prove lethal if not recognized early.
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Affiliation(s)
- Mohammad Al Mawed
- Klinik für Kardiologie, Angiologie und internistische Intensivmedizin, Klinikum Lippe GmbH, Detmold, North Rhine-Westphalia, Germany
| | - Marios Vlachojannis
- Klinik für Kardiologie, Angiologie und internistische Intensivmedizin, Klinikum Lippe GmbH, Detmold, North Rhine-Westphalia, Germany
| | - Arianit Pula
- Klinik für Kardiologie, Angiologie und internistische Intensivmedizin, Klinikum Lippe GmbH, Detmold, North Rhine-Westphalia, Germany
| | - Stephan Gielen
- Klinik für Kardiologie, Angiologie und internistische Intensivmedizin, Klinikum Lippe GmbH, Detmold, North Rhine-Westphalia, Germany
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5
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Kostantinis S, Simsek B, Karacsonyi J, Alaswad K, Jaffer FA, Khatri JJ, Choi JW, Jaber WA, Rinfret S, Nicholson W, Patel MP, Mahmud E, Toma C, Davies RE, Kerrigan JL, Haddad EV, Gorgulu S, Abi-Rafeh N, ElGuindy AM, Goktekin O, Allana S, Burke MN, Mastrodemos OC, Rangan BV, Brilakis E. Development and validation of a scoring system for predicting clinical coronary artery perforation during percutaneous coronary intervention of chronic total occlusions: the PROGRESS-CTO perforation score. EUROINTERVENTION 2023; 18:1022-1030. [PMID: 36281650 PMCID: PMC9853034 DOI: 10.4244/eij-d-22-00593] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 09/12/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND Coronary artery perforation is a feared complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) and often leads to serious adverse clinical events. AIMS We sought to develop a risk score to predict clinical coronary artery perforation in patients undergoing CTO PCI. METHODS We analysed clinical and angiographic parameters from 9,618 CTO PCIs in the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO). Logistic regression prediction modelling was used to identify variables independently associated with clinical perforation, and the model was internally validated with bootstrapping. Clinical coronary artery perforation was defined as any perforation requiring treatment. RESULTS The incidence of clinical coronary perforation was 3.8% (n=367). Five factors were independently associated with perforation and were included in the score: patient age ≥65 years +1 point (odds ratio [OR] 1.79, 95% confidence interval [CI]: 1.37-2.33), moderate/severe calcification +1 point (OR 1.85, 95% CI: 1.41-2.42), blunt/no stump +1 point (OR 1.45, 95% CI: 1.10-1.92), use of antegrade dissection and re-entry +1 point (OR 2.43, 95% CI: 1.61-3.69), and use of the retrograde approach +2 points (OR 4.02, 95% CI: 2.95-5.46). The resulting score showed acceptable performance on receiver operating characteristic (ROC) curve (area under the curve [AUC]: 0.741, 95% CI: 0.712-0.773). The Hosmer-Lemeshow test indicated a good fit (p=0.991), and internal validation with bootstrapping demonstrated good agreement with the model with observed AUC: 0.736 (95% bias-corrected CI: 0.706-0.767). CONCLUSIONS The PROGRESS-CTO perforation score may be a useful tool for predicting clinical coronary perforation during CTO PCI.
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Affiliation(s)
- Spyridon Kostantinis
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Bahadir Simsek
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Judit Karacsonyi
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | | | | | | | - James W Choi
- Texas Health Presbyterian Hospital, Dallas, TX, USA
| | | | | | | | | | | | - Catalin Toma
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | | | - Elias V Haddad
- Ascension Saint Thomas Heart Hospital, Nashville, TN, USA
| | | | | | | | | | - Salman Allana
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - M Nicholas Burke
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Olga C Mastrodemos
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Bavana V Rangan
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Emmanouil Brilakis
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
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6
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Sianos G, Al Nooryani A. Scores and algorithms in CTO PCI: "PROGRESS" or an exercise in futility? EUROINTERVENTION 2023; 18:955-956. [PMID: 36688456 PMCID: PMC9853025 DOI: 10.4244/eij-e-22-00049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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7
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Matsuura H, Mukai Y, Honda Y, Nishino S, Kang H, Kadooka K, Ogata K, Kimura T, Koiwaya H, Nishihira K, Kuriyama N, Shibata Y. Intra- and Postprocedural Management of Coronary Artery Perforation During Percutaneous Coronary Intervention. Circ Rep 2022; 4:517-525. [DOI: 10.1253/circrep.cr-22-0092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 09/07/2022] [Indexed: 11/11/2022] Open
Affiliation(s)
- Hirohide Matsuura
- Department of Cardiology, Miyazaki Medical Association Hospital Cardiovascular Center
| | - Yasushi Mukai
- Department of Cardiology, Japanese Red Cross Fukuoka Hospital
| | - Yasuhiro Honda
- Department of Cardiology, Miyazaki Medical Association Hospital Cardiovascular Center
| | - Shun Nishino
- Department of Cardiology, Miyazaki Medical Association Hospital Cardiovascular Center
| | - Honsa Kang
- Department of Cardiology, Miyazaki Medical Association Hospital Cardiovascular Center
| | - Kosuke Kadooka
- Department of Cardiology, Miyazaki Medical Association Hospital Cardiovascular Center
| | - Kenji Ogata
- Department of Cardiology, Miyazaki Medical Association Hospital Cardiovascular Center
| | - Toshiyuki Kimura
- Department of Cardiology, Miyazaki Medical Association Hospital Cardiovascular Center
| | - Hiroshi Koiwaya
- Department of Cardiology, Miyazaki Medical Association Hospital Cardiovascular Center
| | - Kensaku Nishihira
- Department of Cardiology, Miyazaki Medical Association Hospital Cardiovascular Center
| | - Nehiro Kuriyama
- Department of Cardiology, Miyazaki Medical Association Hospital Cardiovascular Center
| | - Yoshisato Shibata
- Department of Cardiology, Miyazaki Medical Association Hospital Cardiovascular Center
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8
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Mikhail P, Howden N, Monjur M, Jeyaprakash P, Said C, Bland A, Collison D, McCartney P, Adamson C, Morrow A, Carrick D, McEntegart M, Ford TJ. Coronary perforation incidence, outcomes and temporal trends (COPIT): a systematic review and meta-analysis. Open Heart 2022; 9:openhrt-2022-002076. [PMID: 36270713 PMCID: PMC9594565 DOI: 10.1136/openhrt-2022-002076] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/06/2022] [Indexed: 11/13/2022] Open
Abstract
Coronary perforation is a potentially life-threatening complication of percutaneous coronary intervention (PCI). We studied incidence, outcomes and temporal trends following PCI-related coronary artery perforation (CAP). METHODS Prospective systematic review and meta-analysis including meta-regression using MEDLINE and EMBASE to November 2020. We included 'all-comer' PCI cohorts including large PCI registries and randomised controlled trials and excluding registries or trials limited to PCI in high-risk populations such as chronic total occlusion PCI or cohorts treated only with atheroablative devices. Regression analysis and corresponding correlation coefficients were performed comparing perforation incidence, mortality rate, tamponade rate and the rate of Ellis III perforations against the midpoint (year) of data collection to determine if a significant temporal relationship was present. RESULTS 3997 studies were screened for inclusion. 67 studies met eligibility criteria with a total of 5 568 191 PCIs included over a 38-year period (1982-2020). The overall pooled incidence of perforation was 0.39% (95% CI 0.34% to 0.45%) and remained similar throughout the study period. Around 1 in 5 coronary perforations led to tamponade (21.1%). Ellis III perforations are increasing in frequency and account for 43% of all perforations. Perforation mortality has trended lower over the years (7.5%; 95% CI 6.7% to 8.4%). Perforation risk factors derived using meta-regression were female sex, hypertension, chronic kidney disease and previous coronary bypass grafting. Coronary perforation was most frequently caused by distal wire exit (37%) followed by balloon dilation catheters (28%). Covered stents were used to treat 25% of perforations, with emergency cardiac surgery needed in 17%. CONCLUSION Coronary perforation complicates approximately 1 in 250 PCIs. Ellis III perforations are increasing in incidence although it is unclear whether this is due to reporting bias. Despite this, the overall perforation mortality rate (7.5%) has trended lower in recent years. Limitations of our findings include bias that may be introduced through analysis of multidesign studies and registries without pre-specified standardised perforation reporting CMore research into coronary perforation management including the optimal use of covered stents seems warranted. PROSPERO REGISTRATION NUMBER CRD42020207881.
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Affiliation(s)
- Philopatir Mikhail
- Department of Cardiology, Central Coast Local Health District, Gosford, New South Wales, Australia,Faculty of Medicine, The University of Newcastle, Newcastle, NSW, Australia
| | - Nicklas Howden
- Department of Cardiology, Central Coast Local Health District, Gosford, New South Wales, Australia,Faculty of Medicine, The University of Newcastle, Newcastle, NSW, Australia
| | - Mohammad Monjur
- Department of Cardiology, South Eastern Sydney Local Health District, Kogarah, New South Wales, Australia
| | - Prajith Jeyaprakash
- Department of Cardiology, Nepean Hospital, Penrith, New South Wales, Australia
| | - Christian Said
- Department of Cardiology, Central Coast Local Health District, Gosford, New South Wales, Australia
| | - Adam Bland
- Department of Cardiology, Central Coast Local Health District, Gosford, New South Wales, Australia,Faculty of Medicine, The University of Newcastle, Newcastle, NSW, Australia
| | - Damien Collison
- Department of Cardiology, Golden Jubilee Hospital, Clydebank, UK,Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Peter McCartney
- Department of Cardiology, Golden Jubilee Hospital, Clydebank, UK,Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Carly Adamson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Andrew Morrow
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - David Carrick
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK,Department of Cardiology, University Hospital Hairmyres, East Kilbride, UK
| | | | - Thomas J Ford
- Department of Cardiology, Central Coast Local Health District, Gosford, New South Wales, Australia,Faculty of Medicine, The University of Newcastle, Newcastle, NSW, Australia,Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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9
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Kostantinis S, Simsek B, Karacsonyi J, Alaswad K, Krestyaninov O, Khelimskii D, Karmpaliotis D, Jaffer FA, Khatri JJ, Poommipanit P, Jaber WA, Rinfret S, Nicholson W, Patel MP, Mahmud E, Koutouzis M, Tsiafoutis I, Benton SM, Davies RE, Toma C, Kerrigan JL, Haddad EV, Abi-Rafeh N, ElGuindy AM, Goktekin O, Mastrodemos OC, Rangan BV, Burke MN, Brilakis ES. Incidence, Mechanisms, Treatment, and Outcomes of Coronary Artery Perforation During Chronic Total Occlusion Percutaneous Coronary Intervention. Am J Cardiol 2022; 182:17-24. [PMID: 36028387 DOI: 10.1016/j.amjcard.2022.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/24/2022] [Accepted: 07/05/2022] [Indexed: 11/28/2022]
Abstract
Coronary artery perforation is a feared complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Our objective was to describe the incidence, mechanisms, treatment, and outcomes of coronary artery perforation during CTO PCI. We analyzed the baseline clinical and angiographic characteristics and procedural outcomes of 10,454 CTO PCIs performed in 10,219 patients between 2012 and 2022. The incidence of coronary perforation was 4.9% (n = 503). Patients who experienced coronary perforation were older and were more likely to have had previous coronary artery bypass graft surgery. Procedures that resulted in perforation were more complex, with higher Japanese CTO and Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) scores. Technical (66% vs 87%, p <0.001) and procedural (55% vs 87%, p <0.001) success rates were lower in perforation cases. The CTO target vessel was the most common perforation site (66%). The retrograde approach was responsible for the perforation in 47% of cases, and guidewire exit was the most common perforation mechanism. The proportion of Ellis class 1, 2, 3, and 3 -"cavity spilling" coronary perforations was 20%, 41%, 28%, and 11%, respectively. In 52% of perforations, 1 or more interventions were required: prolonged balloon inflation (23%), covered stent deployment (21%), coil embolization (6%), and/or autologous fat embolization (4%). Tamponade requiring pericardiocentesis occurred in 69 patients (14%). The incidence of major adverse cardiovascular events was higher in perforation cases (18% vs 1.3%, p <0.001). In conclusion, coronary artery perforation occurred in 4.9% of CTO PCIs performed by experienced operators and was associated with lower technical success and higher in-hospital major adverse cardiovascular events.
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Affiliation(s)
- Spyridon Kostantinis
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Bahadir Simsek
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Judit Karacsonyi
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Khaldoon Alaswad
- Division of Cardiology, Henry Ford Cardiovascular Division, Detroit, Michigan
| | - Oleg Krestyaninov
- Department of Invasive Cardiology, Meshalkin Novosibirsk Research Institute, Novosibirsk, Russia
| | - Dmitrii Khelimskii
- Department of Invasive Cardiology, Meshalkin Novosibirsk Research Institute, Novosibirsk, Russia
| | - Dimitri Karmpaliotis
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey
| | - Farouc A Jaffer
- Cardiovascular Research Center and Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Paul Poommipanit
- Section of Cardiology, University Hospitals, Case Western Reserve University, Cleveland, Ohio
| | - Wissam A Jaber
- Emory Heart and Vascular Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - Stephane Rinfret
- Emory Heart and Vascular Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - William Nicholson
- Emory Heart and Vascular Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - Mitul P Patel
- Division of Cardiovascular Medicine, University of California San Diego Medical Center, San Diego, California
| | - Ehtisham Mahmud
- Division of Cardiovascular Medicine, University of California San Diego Medical Center, San Diego, California
| | - Michael Koutouzis
- Department of Cardiology, Red Cross Hospital of Athens, Athens, Greece
| | | | - Stewart M Benton
- Department of Cardiology, Wellspan York Hospital, York, Pennsylvania
| | - Rhian E Davies
- Department of Cardiology, Wellspan York Hospital, York, Pennsylvania
| | - Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jimmy L Kerrigan
- Department of Cardiology, Saint Thomas Heart Hospital, Nashville, Tennessee
| | - Elias V Haddad
- Department of Cardiology, Saint Thomas Heart Hospital, Nashville, Tennessee
| | - Nidal Abi-Rafeh
- Department of Cardiology, North Oaks Health System, Hammond, Louisiana
| | | | - Omer Goktekin
- Department of Cardiology, Memorial Bahcelievler Hospital, Istanbul, Turkey
| | - Olga C Mastrodemos
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Bavana V Rangan
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - M Nicholas Burke
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Emmanouil S Brilakis
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota.
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Pavani M, Cerrato E, Franzè A, Colombo F, Ryan N, Durante A, Bellini B, Calcagno S, Montorfano M, Gonzalo N, Azzalini L, Escaned J, Varbella F. Grade 3 coronary artery perforations in chronic total occlusion-percutaneous coronary intervention: Mechanisms, locations, and outcomes from the G3CAP Registry. Catheter Cardiovasc Interv 2022; 100:190-198. [PMID: 35686523 DOI: 10.1002/ccd.30293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/20/2022] [Indexed: 11/09/2022]
Abstract
AIM The impact of Grade III coronary perforations (G3-CP) in the setting of CTO-PCI is not well assessed. METHODS AND RESULTS We reviewed 7773 CTO-PCI and 98,819 non CTO-PCI performed in 10 European centers: G3 perforation occurred in 87 patients (1.1%) during CTO PCI and 224 patients (0.22%) during non CTO-PCI (p < 0.001). G3-CP involved the CTO segment in 68% of patients and the retrograde channels in 14% of cases. In the CTO PCI group, wire induced G3-CP (50.5% vs. 32.5%, p = 0.02) occurred predominantly when dedicated CTO tapered and highly penetrative wires were used. Intra-procedural and in-hospital death rates were 4.6% vs. 5.8% and 3.6% vs. 7.5% respectively for CTO PCI and non-CTO PCI groups (p = NS). At a median follow up of 24 months, the overall mortality and MAE were respectively 7.8% and MAE 19% without difference among groups. CONCLUSIONS We showed similar in-hospital and long-term outcomes when G3 perforations occurred during CTO PCI and non CTO-PCI.
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Affiliation(s)
- Marco Pavani
- Interventional Unit, Infermi Hospital, Rivoli, Turin, Italy.,AOU San Luigi Gonzaga, Orbassano, Turin, Italy
| | - Enrico Cerrato
- Interventional Unit, Infermi Hospital, Rivoli, Turin, Italy.,AOU San Luigi Gonzaga, Orbassano, Turin, Italy
| | - Alfonso Franzè
- Interventional Unit, Infermi Hospital, Rivoli, Turin, Italy.,AOU San Luigi Gonzaga, Orbassano, Turin, Italy
| | | | - Nicola Ryan
- Department of Cardiology, Aberdeeen Royal Infirmary, Aberdeen, Scotland
| | | | - Barbara Bellini
- Interventional Cardiology Division, Cardio-Thoracic Vascular Department, San Raffaele Scientific Institute, Milan, Italy
| | - Simone Calcagno
- Cardiology Department, Umberto I Hospital, Sapienza University of Rome, Rome, Italy
| | - Matteo Montorfano
- Interventional Cardiology Division, Cardio-Thoracic Vascular Department, San Raffaele Scientific Institute, Milan, Italy
| | - Nieves Gonzalo
- Cardiologia Interventionista, Hospital Clinico San Carlos, Madrid, Spain
| | - Lorenzo Azzalini
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Javier Escaned
- Cardiologia Interventionista, Hospital Clinico San Carlos, Madrid, Spain
| | - Ferdinando Varbella
- Interventional Unit, Infermi Hospital, Rivoli, Turin, Italy.,AOU San Luigi Gonzaga, Orbassano, Turin, Italy
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Kandzari DE, Sarao RC, Waksman R. Clinical experience of the PK Papyrus covered stent in patients with coronary artery perforations: Results from a multi-center humanitarian device exemption survey. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 43:97-101. [DOI: 10.1016/j.carrev.2022.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/14/2022] [Accepted: 04/19/2022] [Indexed: 12/20/2022]
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12
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Wang R, He Y, Xing H, Zhang D, Tian J, Le Y, Zhang L, Chen H, Song X, Wang Z. Inclusion of quantitative high-density plaque in coronary computed tomographic score system to predict the time of guidewire crossing chronic total occlusion. Eur Radiol 2022; 32:4565-4573. [PMID: 35182204 PMCID: PMC9213281 DOI: 10.1007/s00330-022-08564-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 12/01/2021] [Accepted: 01/04/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to establish a new scoring system that includes histological quantitative features derived from coronary computed tomographic angiography (CCTA) to predict the efficiency of chronic total occlusion percutaneous coronary intervention (CTO-PCI). METHODS This study analyzed clinical, morphological, and histological characteristics of 207 CTO lesions in 201 patients (mean age 60.0 [52.0-65.0] years, 85% male), which were recruited from two centers. The primary endpoint was a guidewire successfully crossing the lesions within 30 m. The new predictive model was generated by factors that were determined by multivariate analysis. The CCTA plaque (CTAP) score that included a quantitative plaque characteristic was developed by assigning an appropriate integer score to each independent predictor, then summing all points. In addition, the CTAP score was compared with other predictive scores based on CCTA. RESULTS The endpoint was achieved in 63% of the lesions. The independent predictors included previous CTO-PCI failure, the proximal blunt stump, proximal side branch, distal side branch, occluded segment bending > 45°, and high-density plaque volume (fibrous volume + calcified volume) ≥ 19.9 mm3. As the score increased from 0 to 5, the success rate of the guidewire crossing within 30 m decreased from 96 to 0%. Comparing the CTAP score with other predictive scores, the CTAP score showed the highest discriminant power (c-statistic = 0.81 versus 0.73-0.77, p value 0.02-0.07). The CTAP score showed similar results for procedural success. CONCLUSION The CTAP score efficiently predicted the guidewire crossing efficiency and procedural success. KEY POINTS • An increase in high-density plaque volume (fibrous + dense calcium) was more probable to reduce the efficiency of crossing and lead to procedural failure. • The new prediction scoring system with the addition of the quantitative characteristics of plaques had an improved predictive ability compared with the traditional prediction scoring system.
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Affiliation(s)
- Rui Wang
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, No. 95, Yong An Road, Xicheng District, Beijing, 100050, China
- Department of Radiology, Affiliated Hospital, Chengde Medical University, Chengde, Hebei, China
| | - Yi He
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, No. 95, Yong An Road, Xicheng District, Beijing, 100050, China
| | - Haoran Xing
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
- Beijing Lab for Cardiovascular Precision Medicine, Beijing, China
| | - Dongfeng Zhang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
- Beijing Lab for Cardiovascular Precision Medicine, Beijing, China
| | - Jinfan Tian
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
- Beijing Lab for Cardiovascular Precision Medicine, Beijing, China
| | - Yinghui Le
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, No. 95, Yong An Road, Xicheng District, Beijing, 100050, China
| | - Lijun Zhang
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hui Chen
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xiantao Song
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
- Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China.
- Beijing Lab for Cardiovascular Precision Medicine, Beijing, China.
| | - Zhenchang Wang
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, No. 95, Yong An Road, Xicheng District, Beijing, 100050, China.
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Jacob D, Savage MP, Fischman DL. Novel Approaches to Coronary Perforations. JACC Case Rep 2022; 4:142-144. [PMID: 35201242 PMCID: PMC8853945 DOI: 10.1016/j.jaccas.2021.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Cerrato E, Pavani M, Barbero U, Colombo F, Mangieri A, Ryan N, Quadri G, Tomassini F, Presutti DG, Calcagno S, Franzè A, Bellini B, D'Ascenzo F, Ielasi A, De Benedictis M, Azzalini L, Mancone M, Escaned J, Montorfano M, Latib A, Varbella F. Incidence, Management, Immediate and Long-Term Outcome of Guidewire and Device Related Grade III Coronary Perforations (from G3CAP - Cardiogroup VI Registry). Am J Cardiol 2021; 143:37-45. [PMID: 33387472 DOI: 10.1016/j.amjcard.2020.12.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/22/2020] [Accepted: 12/01/2020] [Indexed: 12/30/2022]
Abstract
Ellis grade III coronary artery perforations (G3-CAP) remain a life-threatening complication of percutaneous coronary intervention (PCI), with high morbidity and mortality and lack of consensus regarding optimal treatment strategies. We reviewed all PCIs performed in 10 European centers from 1993 to 2019 recording all G3-CAP along with management strategies, in-hospital and long-term outcome according to Device-related perforations (DP) and Guidewire-related perforations (WP). Among 106,592 PCI (including 7,773 chronic total occlusions), G3-CAP occurred in 311 patients (0.29%). DP occurred in 194 cases (62.4%), more commonly in proximal segments (73.2%) and frequently secondary to balloon dilatation (66.0%). WP arose in 117 patients (37.6%) with chronic total occlusions guidewires involved in 61.3% of cases. Overall sealing success rate was 90.7% and usually required multiple maneuvers (80.4%). The most commonly adopted strategies to obtain hemostasis were prolonged balloon inflation (73.2%) with covered stent implantation (64.4%) in the DP group, and prolonged balloon inflation (53.8%) with coil embolization (41%) in the WP group. Procedural or in-hospital events arose in 38.2% of cases: mortality was higher after DP (7.2% vs 2.6%, p = 0.05) and acute stent thrombosis 3-fold higher (3.1% vs 0.9%, p = 0.19). At clinical follow-up, median 2 years, a major cardiovascular event occurred in one-third of cases (all-cause mortality 8.2% and 7.1% respectively, without differences between groups). In conclusion, although rare and despite improved rates of adequate perforation sealing G3-CAP cause significant adverse events. DP and WP result in different patterns of G3-CAP and management strategies should be based on this classification.
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Affiliation(s)
- Enrico Cerrato
- Interventional Cardiology Unit, San Luigi Gonzaga University Hospital (Orbassano) and Rivoli Infermi Hospital (Rivoli), Turin, Italy; Montefiore Medical Center, New York, New York.
| | - Marco Pavani
- Cardiology Unit, Santissima Annunziata Hospital, ASL CN1, Savigliano (CN), Italy
| | - Umberto Barbero
- Cardiology Unit, Santissima Annunziata Hospital, ASL CN1, Savigliano (CN), Italy
| | | | - Antonio Mangieri
- Interventional Cardiology Unit, San Raffaele Hospital, Milan, Italy
| | - Nicola Ryan
- Department of Cardiology, Aberdeen Royal Infirmary, Aberdeen, Scotland
| | - Giorgio Quadri
- Interventional Cardiology Unit, San Luigi Gonzaga University Hospital (Orbassano) and Rivoli Infermi Hospital (Rivoli), Turin, Italy
| | - Francesco Tomassini
- Interventional Cardiology Unit, San Luigi Gonzaga University Hospital (Orbassano) and Rivoli Infermi Hospital (Rivoli), Turin, Italy
| | | | - Simone Calcagno
- Department of Clinical Internal, Anesthesiological and Cardiovascular Science, Sapienza University of Rome, Rome, Italy
| | - Alfonso Franzè
- Interventional Cardiology Unit, San Luigi Gonzaga University Hospital (Orbassano) and Rivoli Infermi Hospital (Rivoli), Turin, Italy
| | - Barbara Bellini
- Interventional Cardiology Unit, San Raffaele Hospital, Milan, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Città della Salute e della Scienza di Torino, Turin, Italy; Montefiore Medical Center, New York, New York
| | - Alfonso Ielasi
- Clinical and Interventional Cardiology Unit, Sant'Ambrogio Cardio-Thoracic Center, Milan, Italy
| | | | - Lorenzo Azzalini
- Division of Cardiology, VCU Health Pauley Heart Center and Virginia Commonwealth University, Richmond, Virginia
| | - Massimo Mancone
- Department of Clinical Internal, Anesthesiological and Cardiovascular Science, Sapienza University of Rome, Rome, Italy
| | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, Madrid, Spain
| | | | - Azeem Latib
- Montefiore Medical Center, New York, New York
| | - Ferdinando Varbella
- Interventional Cardiology Unit, San Luigi Gonzaga University Hospital (Orbassano) and Rivoli Infermi Hospital (Rivoli), Turin, Italy
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Five-year report from the Polish national registry on percutaneous coronary interventions with a focus on coronary artery perforations within chronic total occlusions. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2021; 16:399-409. [PMID: 33598012 PMCID: PMC7863825 DOI: 10.5114/aic.2020.101764] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 09/13/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Patients treated within chronic total occlusions (CTO) using percutaneous coronary intervention (PCI) are at increased risk of periprocedural complications. Aim To assess the frequency of periprocedural complications with particular emphasis on coronary artery perforations (CAPs) among patients treated with PCIs stratified according to CTOs and their predictors. Material and methods Based on a nationwide registry (ORPKI), we analysed 535,853 patients treated with PCI between 2014 and 2018. The study included 12,572 (2.34%) patients treated with CTO PCI. We compared CTO PCI to a non-CTO PCI group before and after propensity score matching (PSM). Multifactorial mixed regression models were used to assess predictors of periprocedural complications and CAPs which occurred within the catheterization laboratory. Results Frequencies of all periprocedural complications (2.75% vs. 1.93%, p < 0.001) and CAP (0.72% vs. 0.16%, p < 0.001) were significantly higher in the CTO PCI group. Multifactorial regression analysis performed in the all-comers group of patients treated with PCI showed that PCI within CTO was related to a higher CAP rate (odds ratio (OR) = 2.18; 95% confidence interval (CI): 1.68–2.82, p < 0.001). After PSM, we extracted 5,652 patients treated within CTO and 5,652 patients with non-CTO PCI. CTO PCI was also related to a higher frequency of CAPs (OR = 1.89; 95% CI: 1.11–3.31, p = 0.01). Conclusions The frequency of periprocedural complications and CAPs remained stable during the assessed period of time. CTO PCI was confirmed to be among the predictors of increased CAP rate in the overall group of patients treated within CTO.
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Prevalence, clinical determinants and prognostic implications of coronary procedural complications of percutaneous coronary intervention in non-ST-segment elevation myocardial infarction: Insights from the contemporary multinational TAO trial. Arch Cardiovasc Dis 2021; 114:187-196. [PMID: 33518473 DOI: 10.1016/j.acvd.2020.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 07/11/2020] [Accepted: 09/07/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Few data are available on procedural complications of percutaneous coronary intervention (PCI) in the setting of acute coronary syndrome in the contemporary era. AIM We sought to describe the prevalence of procedural complications of PCI in a non-ST-segment elevation acute coronary syndrome (NSTE ACS) cohort, and to identify their clinical characteristics and association with clinical outcomes. METHODS Patients randomized in TAO (Treatment of Acute coronary syndrome with Otamixaban), an international randomized controlled trial (ClinicalTrials.gov Identifier: NCT01076764) that compared otamixaban with unfractionated heparin plus eptifibatide in patients with NSTE ACS who underwent PCI, were included in the analysis. Procedural complications were collected prospectively, categorized and adjudicated by a blinded Clinical Events Committee, with review of angiograms. A multivariable model was constructed to identify independent clinical characteristics associated with procedural complications. RESULTS A total of 8656 patients with NSTE ACS who were enrolled in the TAO trial underwent PCI, and 451 (5.2%) experienced at least one complication. The most frequent complications were no/slow reflow (1.5%) and dissection with decreased flow (1.2%). Procedural complications were associated with the 7-day ischaemic outcome of death, myocardial infarction or stroke (24.2% vs. 6.0%, odds ratio 5.01, 95% confidence interval 3.96-6.33; P<0.0001) and with Thrombolysis In Myocardial Infarction major and minor bleeding (6.2% vs. 2.3%, odds ratio 2.79, 95% confidence interval 1.86-4.2; P<0.0001). Except for previous coronary artery bypass grafting, multivariable analysis did not identify preprocedural clinical predictors of complications. CONCLUSIONS In a contemporary NSTE ACS population, procedural complications with PCI remain frequent, are difficult to predict based on clinical characteristics, and are associated with worse ischaemic and haemorrhagic outcomes.
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Moroni F, Brilakis ES, Azzalini L. Chronic total occlusion percutaneous coronary intervention: managing perforation complications. Expert Rev Cardiovasc Ther 2021; 19:71-87. [PMID: 33175595 DOI: 10.1080/14779072.2021.1850264] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Coronary artery perforation (CAP) is an infrequent (<1%) complication of percutaneous coronary intervention (PCI), that can lead to dramatic consequences, including tamponade and death. The incidence of CAP is higher (4-9%) in chronic total occlusion (CTO) PCI due higher complexity of these lesions and the techniques used to recanalized them. AREAS COVERED In this Expert Review, we discuss the specific features of CTO PCI predisposing to CAP. We also describe the typical procedural scenarios in which CAP can occur and provide a universal management algorithm. Currently available devices and techniques for CAP treatment are presented in detail. Finally, we discuss imaging support for diagnosis of pericardial effusion in CAP as well as medical and surgical management. EXPERT OPINION With increasing volumes and complexity of CTO PCI, the incidence of CAP is likely to rise. Adherence to good catheterization laboratory practices, availability of dedicated equipment to seal CAP, perform pericardiocentesis, and provide hemodynamic support, as well as adequate training, are pillars for the prevention and optimal management of CAP during CTO PCI.
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Affiliation(s)
| | - Emmanouil S Brilakis
- Minneapolis Heart Institute, Abbott Northwestern Hospital , Minneapolis, MN, USA
| | - Lorenzo Azzalini
- Division of Cardiology, VCU Health Pauley Heart Center, Virginia Commonwealth University , Richmond, VA, USA
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Tremmel JA. Perforation Mechanisms, Risk Stratification, and Management in the Non-post Coronary Artery Bypass Graft Patient. Interv Cardiol Clin 2020; 10:93-99. [PMID: 33223111 DOI: 10.1016/j.iccl.2020.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Jennifer A Tremmel
- Stanford University Medical Center, 300 Pasteur Drive, Room H2103, Stanford, CA 94305, USA.
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19
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Barbero U, Cerrato E, Secco GG, Tedeschi D, Belliggiano D, Pavani M, Moncalvo C, Tomassini F, De Benedictis M, Doronzo B, Varbella F. PK Papyrus coronary stent system: the ultrathin struts polyurethane-covered stent. Future Cardiol 2020; 16:405-411. [DOI: 10.2217/fca-2020-0022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
In the emergency setting of a coronary vessel perforation, the knowledge of materials needed to fix it and the intrinsic quality of the device used is mandatory for the interventional cardiologist. The PK Papyrus covered stent (Biotronik AG) is an ultrathin strut (60 μm) balloon-expandable stent covered on the abluminal surface with an electrospun polyurethane matrix. It is intended to facilitate device delivery and effectively treat coronary artery perforations. In published studies, rates of successful device delivery and perforation sealing were above 90%, respectively, and most events were usually resolved with a single stent. In this review we focused on the main technical characteristics as well on the published evidence that compare its performance with other coronary covered stent.
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Affiliation(s)
- Umberto Barbero
- Cardiology Department, Santissima Annunziata Hospital, Savigliano, Italy
| | - Enrico Cerrato
- Interventional Cardiology, Infermi Hospital, Rivoli & San Luigi Gonzaga, Orbassano, Turin, Italy
- Cardiology Department, San Luigi Gonzaga University Hospital, Orbassano, Turin, Italy
| | - Gioel Gabrio Secco
- Interventional Cardiology, Santi Antonio, Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Delio Tedeschi
- Interventional Cardiology, Istituto Clinico S.Anna Gruppo Ospedaliero San Donato, Brescia, Italy
| | - Davide Belliggiano
- Cardiology Department, San Luigi Gonzaga University Hospital, Orbassano, Turin, Italy
| | - Marco Pavani
- Cardiology Department, Santissima Annunziata Hospital, Savigliano, Italy
| | - Cinzia Moncalvo
- Cardiology Department, Santissima Annunziata Hospital, Savigliano, Italy
| | - Francesco Tomassini
- Interventional Cardiology, Infermi Hospital, Rivoli & San Luigi Gonzaga, Orbassano, Turin, Italy
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Hooda A, Masoomi R, Jain T, Johal GS, Barman N, Sharma SK. Rotational Atherectomy Induced Coronary Perforation of Right Coronary Artery Draining into Middle Cardiac Vein. JACC Case Rep 2020; 2:1688-1691. [PMID: 34317035 PMCID: PMC8312102 DOI: 10.1016/j.jaccas.2020.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/16/2020] [Indexed: 11/29/2022]
Abstract
Ellis Type III cavity spilling coronary perforation is a rare complication. We report to our knowledge, the first case of rotational atherectomy induced Type III cavity spilling coronary perforation of right posterior descending artery draining into middle cardiac vein, successfully managed by covered stent deployment. (Level of Difficulty: Advanced.)
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Affiliation(s)
- Amit Hooda
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Reza Masoomi
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Tarun Jain
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Gurpreet S Johal
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Nitin Barman
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Samin K Sharma
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
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21
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Doll JA, Hira RS, Kearney KE, Kandzari DE, Riley RF, Marso SP, Grantham JA, Thompson CA, McCabe JM, Karmpaliotis D, Kirtane AJ, Lombardi W. Management of Percutaneous Coronary Intervention Complications: Algorithms From the 2018 and 2019 Seattle Percutaneous Coronary Intervention Complications Conference. Circ Cardiovasc Interv 2020; 13:e008962. [PMID: 32527193 DOI: 10.1161/circinterventions.120.008962] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Complications of percutaneous coronary intervention (PCI) may have significant impact on patient survival and healthcare costs. PCI procedural complexity and patient risk are increasing, and operators must be prepared to recognize and treat complications, such as perforations, dissections, hemodynamic collapse, no-reflow, and entrapped equipment. Unfortunately, few resources exist to train operators in PCI complication management. Uncertainty regarding complication management could contribute to the undertreatment of patients with high-complexity coronary disease. We, therefore, coordinated the Learning From Complications: How to Be a Better Interventionalist courses to disseminate the collective experience of high-volume PCI operators with extensive experience in chronic total occlusion and high-risk PCI. From these conferences in 2018 and 2019, we developed algorithms that emphasize early recognition, effective treatment, and team-based care of PCI complications. We think that an algorithmic approach will result in a logical and systematic response to life-threatening complications. This construct may be useful for operators who plan to perform complex PCI procedures.
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Affiliation(s)
- Jacob A Doll
- University of Washington, Seattle, WA (J.A.D., R.S.H., K.E.K., J.M.M., W.L.).,VA Puget Sound Health Care System, Seattle, WA (J.A.D.)
| | - Ravi S Hira
- University of Washington, Seattle, WA (J.A.D., R.S.H., K.E.K., J.M.M., W.L.)
| | - Kathleen E Kearney
- University of Washington, Seattle, WA (J.A.D., R.S.H., K.E.K., J.M.M., W.L.)
| | | | - Robert F Riley
- The Christ Hospital Health Network, Cincinnati, OH (R.F.R.)
| | - Steven P Marso
- HCA Midwest Health Heart and Vascular Institute, Overland Park, KS (S.P.M.)
| | - James A Grantham
- Saint Luke's Mid America Heart Institute, Kansas City, MO (J.A.G.).,University of Missouri-Kansas City, Kansas City, MO (J.A.G.)
| | | | - James M McCabe
- University of Washington, Seattle, WA (J.A.D., R.S.H., K.E.K., J.M.M., W.L.)
| | | | - Ajay J Kirtane
- Columbia University Medical Center, New York, NY (D.K., A.J.K.)
| | - William Lombardi
- University of Washington, Seattle, WA (J.A.D., R.S.H., K.E.K., J.M.M., W.L.)
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22
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Harnek J, James S, Lagerqvist B. Coronary Artery Perforation and Tamponade - Incidence, Risk Factors, Predictors and Outcomes From 12 Years' Data of the SCAAR Registry. Circ J 2019; 84:43-53. [PMID: 31813890 DOI: 10.1253/circj.cj-19-0757] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The incidence and short- and long-term outcomes of coronary artery perforation (CAP) are not well described.Methods and Results:We analyzed the characteristics and the short- and long-term outcomes of CAP among 243,149 patients undergoing percutaneous coronary interventions (PCI) from 2005 until 2017 in the national Swedish registry. We identified 1,008 cases of CAP with an incidence of 0.42%. Major adverse event rates were significantly higher in patients with CAP than non-CAP (P<0.001). The 1-year mortality rate was 16% vs. 5.5%, respectively, and the 12-year mortality rate was 52% vs. 34%. The restenosis rate was 5.2% vs. 3.1% and 17% vs. 9%, respectively. The target lesion revascularization rate was 4.2% vs. 2.6% and 10.5% vs. 7%. The stent thrombosis rate was numerically higher, 1.5% vs. 0.8% and 4.5 vs. 2.8%, with no stent thrombosis cases for equine pericardial stent grafts. Among the patients with tamponade a large proportion of cases occurred at the late stage (215/1,008, 21%), and most were not recognized in the cath-lab (167/215, 78%). The mortality rate for late tamponade was similar in patients suffering acute tamponade at 1 year (25.6% vs. 27%) or at 12 years (54% vs. 58%). CONCLUSIONS CAP is associated with an early high excess in morbidity and mortality but with low risk of additional adverse events in the long term. Late tamponade is as deadly as acute tamponade.
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Affiliation(s)
- Jan Harnek
- Department of Coronary Heart Disease and Institute of Clinical Sciences, Lund University
| | - Stefan James
- Department of Medical Sciences, Cardiology, Uppsala University
| | - Bo Lagerqvist
- Department of Medical Sciences, Cardiology, Uppsala University
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23
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Wong SC. Editorial: Is Extreme High-Pressure Balloon the Answer to "Undilatable" Lesions? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 20:1088-1089. [PMID: 31870526 DOI: 10.1016/j.carrev.2019.10.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 10/09/2019] [Indexed: 01/17/2023]
Affiliation(s)
- S Chiu Wong
- Cardiac Cath Lab, F433, Division of Cardiology, Weill Cornell Medicine, 520 E 70th Street, New York, NY 10021, United States of America; NY Presbyterian Hospital - Cornell Campus, United States of America.
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24
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Pericardial tamponade as a complication of invasive cardiac procedures: a review of the literature. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2019; 15:394-403. [PMID: 31933655 PMCID: PMC6956453 DOI: 10.5114/aic.2019.90213] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 10/21/2019] [Indexed: 01/26/2023] Open
Abstract
Cardiac tamponade (CT) is a rare but often life-threatening complication after invasive cardiac procedures. Some procedures favor CT. Furthermore, the incidence depends on patients’ comorbidities, sex and age and operators’ skills. In this paper we review studies and meta-analyses concerning the rate of iatrogenic CT. We define the risk factors of CT and show concise characteristics for each invasive cardiac procedure separately. According to our analysis CT occurs especially after procedures requiring transseptal puncture or perioperative anticoagulation. The overall rate of CT after such procedures varies among published studies from 0.089% to 4.8%. For this purpose we searched the PubMed database for clinical studies published up to December 2018. We included only those studies in which a defined minimum of procedures were performed (1000 for atrial fibrillation ablation, 6000 for percutaneous coronary intervention, 900 for permanent heart rhythm devices, 90 for left atrial appendage closure, 300 for transcatheter aortic valve implantation and percutaneous mitral valve repair with the Mitra-Clip system). The search was structured around the key words and variants of these terms. In addition, secondary source documents were identified by manual review of reference lists, review articles and guidelines. The search was limited to humans and adults (18+ years).
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25
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Azzalini L, Poletti E, Ayoub M, Ojeda S, Zivelonghi C, La Manna A, Bellini B, Lostalo A, Luque A, Venuti G, Montorfano M, Agostoni P, Pan M, Carlino M, Mashayekhi K. Coronary artery perforation during chronic total occlusion percutaneous coronary intervention: epidemiology, mechanisms, management, and outcomes. EUROINTERVENTION 2019; 15:e804-e811. [DOI: 10.4244/eij-d-19-00282] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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26
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May A, Bhagwandeen R, Collins N. Contemporary Management of Coronary Artery Perforation. Heart Lung Circ 2019; 28:e121-e125. [DOI: 10.1016/j.hlc.2019.03.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/10/2019] [Accepted: 03/19/2019] [Indexed: 10/27/2022]
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27
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28
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Harnek J, James SK, Lagerqvist B. Very long-term outcome of coronary covered stents: a report from the SCAAR registry. EUROINTERVENTION 2019; 14:1660-1667. [PMID: 30375337 DOI: 10.4244/eij-d-18-00855] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Covered stents are mostly used for coronary perforations with a high risk of early adverse events; however, their long-term outcome is unknown. The aim of this study was to elucidate the short- and long-term outcome of patients treated with covered stents compared to all other stented patients. METHODS AND RESULTS The Swedish national registries from 2005-2017 disclosed 265 patients who had received 366 covered stents. Their outcomes were compared to all other stented patients (197,948) who had received 320,784 stents. Compared to regular stents, covered stents showed significant differences (p<0.001) in the short and long term in relation to in-stent restenosis (ISR), target lesion revascularisation (TLR), re-infarction (MI), re-PCI and mortality, the rates of which were all higher. The higher mortality was concentrated within the first month, as a landmark analysis at that time point, adjusted for age and procedural indication, demonstrated no future difference in mortality (HR 1.02 [0.78-1.33], p=0.877). Stent thrombosis (ST) within one year was reported to be higher in covered stents than in other stents. However, no ST was reported in equine pericardial covered stents. CONCLUSIONS This observational study including the entire Swedish population shows that patients receiving covered stents have a significantly higher risk of all adverse events. Reassuringly, in the long term, mortality appears to be similar to that in other stented patients.
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Affiliation(s)
- Jan Harnek
- Department of Coronary Heart Disease and Institution of Clinical Sciences, Lund University, Lund, Sweden
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29
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Kinnaird T, Kwok CS, Davies R, Calvert PA, Anderson R, Gallagher S, Sirker A, Ludman P, deBelder M, Stables R, Johnson TW, Kontopantelis E, Curzen N, Mamas M. Coronary perforation complicating percutaneous coronary intervention in patients presenting with an acute coronary syndrome: An analysis of 1013 perforation cases from the British Cardiovascular Intervention Society database. Int J Cardiol 2019; 299:37-42. [PMID: 31253528 DOI: 10.1016/j.ijcard.2019.06.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 05/15/2019] [Accepted: 06/12/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND The evidence base for coronary perforation occurring during percutaneous coronary intervention in patients presenting with an acute coronary syndrome (ACS-PCI) is limited and the specific role of acute pharmacology in its clinical presentation unclear. METHODS AND RESULTS Using the BCIS PCI database, data were analysed on all ACS-PCI procedures performed in England and Wales between 2007 and 2014. Multiple regressions were used to identify predictors of coronary perforation and its association with outcomes. Propensity score matching was used to evaluate the association between differing P2Y12 inhibitors or glycoprotein inhibitors (GPI) and CP. During 270,329 ACS-PCI procedures, 1013 coronary perforations were recorded (0.37%) with a stable annual incidence. In multiple regression analysis, covariates associated with increased frequency of coronary perforation included age, female gender, CTO intervention, number and length of stents used, and rotational atherectomy use, whilst differing P2Y12 inhibitors were not predictive. Using propensity score matching, use of a GPI was independently associated with tamponade (OR 1.50, [1.08-2.06], p = 0.014). The adjusted odds ratios for all clinical outcomes were adversely affected by coronary perforation. CONCLUSIONS Coronary perforation is an infrequent event during ACS-PCI but is closely associated with adverse clinical outcomes. GPI use was associated with higher rates of tamponade.
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Affiliation(s)
- Tim Kinnaird
- Department of Cardiology, University Hospital of Wales, Cardiff, UK; Keele Cardiovascular Research Group, Institute of Applied Clinical Sciences, University of Keele, Stoke-on-Trent, UK.
| | - Chun Shing Kwok
- Keele Cardiovascular Research Group, Institute of Applied Clinical Sciences, University of Keele, Stoke-on-Trent, UK; Royal Stoke Hospital, UHNM, Stoke-on-Trent, UK
| | - Rhodri Davies
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | - Patrick A Calvert
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust Cambridge, UK
| | - Richard Anderson
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | - Sean Gallagher
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | - Alex Sirker
- Department of Cardiology, St Bartholomew's Hospital, London, UK
| | - Peter Ludman
- Department of Cardiology, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
| | - Mark deBelder
- Department of Cardiology, The James Cook University Hospital, Middlesbrough, UK
| | - Rod Stables
- Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital NHS Foundation Trust, UK
| | | | - Evan Kontopantelis
- Keele Cardiovascular Research Group, Institute of Applied Clinical Sciences, University of Keele, Stoke-on-Trent, UK
| | - Nick Curzen
- Coronary Research Group, University Hospital Southampton NHS Trust, School of Medicine, University of Southampton, Southampton, UK
| | - Mamas Mamas
- Keele Cardiovascular Research Group, Institute of Applied Clinical Sciences, University of Keele, Stoke-on-Trent, UK; Royal Stoke Hospital, UHNM, Stoke-on-Trent, UK
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30
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Wu K, Huang Z, Zhong Z, Liao H, Zhou Y, Luo B, Zhang B. Predictors, treatment, and long-term outcomes of coronary perforation during retrograde percutaneous coronary intervention via epicardial collaterals for recanalization of chronic coronary total occlusion. Catheter Cardiovasc Interv 2019; 93:800-809. [PMID: 30690863 DOI: 10.1002/ccd.28093] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 01/03/2019] [Accepted: 01/07/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To investigate predictors, treatment, and long-term outcomes associated with coronary perforation (CP) in patients who underwent retrograde percutaneous coronary intervention (PCI) through epicardial collaterals for chronic total occlusion (CTO). BACKGROUND Data regarding CP during retrograde PCI through epicardial collaterals for CTO are scarce. METHODS We included 155 patients who underwent retrograde CTO PCI through epicardial collaterals at Guangdong Cardiovascular Institute from August 2011 to December 2017. The median follow-up was 2.5 years. Major adverse cardiac events (MACEs) were analyzed using the Kaplan-Meier method, and independent predictors of long-term MACE were determined using a multivariable Cox model. RESULTS CP occurred in 24 (15.5%) patients, with the frequency of Ellis classes 1 or 2 and 3 being 41.7% and 58.3%, respectively. Seven (4.5%) patients had tamponade, which was effectively managed using coil embolization and pericardiocentesis. Renal dysfunction (odds ratio [OR]: 5.27; 95% confidence interval [CI]: 1.47-18.88; P = 0.011), right coronary artery (RCA) CTO (OR: 4.34; 95% CI: 1.29-14.63; P = 0.018), and Epi-CTO score ≥ 2 (OR: 3.27; 95% CI: 1.12-9.58; P = 0.030) were independent predictors of CP. At the 7-year follow-up, 17 patients had MACE. Multivariable analysis revealed that CP was not associated with worse long-term clinical outcomes (hazard ratio: 1.55; 95% CI: 0.45-5.32, P = 0.484). CONCLUSIONS Retrograde CTO PCI through epicardial collaterals is at increased risk of CP, which is associated with renal dysfunction, RCA CTO, and Epi-CTO score ≥ 2. Prompt and proper management of CP is important. CP is not significantly associated with adverse clinical outcomes.
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Affiliation(s)
- Kaize Wu
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, People's Republic of China
| | - Zehan Huang
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, People's Republic of China
| | - Zhian Zhong
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, People's Republic of China
| | - Hongtao Liao
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, People's Republic of China
| | - Yi Zhou
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, People's Republic of China
| | - Bingzheng Luo
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, People's Republic of China
| | - Bin Zhang
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, People's Republic of China
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31
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Verevkin A, von Aspern K, Leontyev S, Lehmann S, Borger MA, Davierwala PM. Early and Long-Term Outcomes in Patients Undergoing Cardiac Surgery Following Iatrogenic Injuries During Percutaneous Coronary Intervention. J Am Heart Assoc 2019; 8:e010940. [PMID: 30612504 PMCID: PMC6405713 DOI: 10.1161/jaha.118.010940] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 11/12/2018] [Indexed: 11/16/2022]
Abstract
Background Iatrogenic coronary artery injuries during percutaneous coronary interventions ( PCI ) often require emergent surgical management. Our study evaluated the early and long-term outcomes in patients undergoing surgical treatment of iatrogenic PCI complications and identified the predictors of operative and long-term mortality. Methods and Results Pre-, intra- and post-operative data and hospital outcomes of 168 consecutive patients undergoing cardiac surgical procedures for iatrogenic complications following PCI between December 1999 and July 2015, were prospectively collected in our computerized database. Logistic and Cox regression analyses were used to identify the independent predictors of operative and long-term mortality. The mean age was 68.5±10.2 years and 35.7% were females. PCI complications included left anterior descending (38.7%), right coronary (29.2%), circumflex (13.1%), left main coronary artery injuries (19.0%), and acute myocardial infarction (66.7%), Type A aortic dissection (7.7%), cardiac tamponade (17.9%), and cardiogenic shock ( CS ) (46.4%). Operative mortality for corrective surgery was 20.8% and was independently predicted by critical preoperative state (odds ratio: 3.5; P=0.01). The 5- and 10-year survival for all patients was 63.9±4.0% and 49.6±5.0%, which improved remarkably in hospital survivors (79.0±4.0% and 64.0±6.0%). Risk factors for long-term mortality were critical preoperative state (hazard ratio: 3.5; P<0.0001) and coronary artery occlusion during PCI (hazard ratio: 2.6; P=0.002). The 5- and 10-year freedom from major adverse cardiac and cerebrovascular events was 59.7±4.0% and 41.9±5.0%. Conclusions Iatrogenic injuries after PCI or coronary angiography requiring surgical correction are associated with a high operative and long-term mortality. Patients developing acute coronary artery occlusion have a more guarded long-term prognosis. Hospital survivors, however, have a superior long-term survival.
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Affiliation(s)
| | | | - Sergey Leontyev
- University department of Cardiac SurgeryLeipzig Heart CenterGermany
| | - Sven Lehmann
- University department of Cardiac SurgeryLeipzig Heart CenterGermany
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32
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Affronti A, Ruel M. Emergency Surgery for Iatrogenic Injuries attributable to Percutaneous Coronary Interventions: When Planning and Time Matter. J Am Heart Assoc 2019; 8:e011525. [PMID: 30612509 PMCID: PMC6405717 DOI: 10.1161/jaha.118.011525] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
See Article by Verevkin et al.
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Affiliation(s)
| | - Marc Ruel
- University of Ottawa Heart InstituteUniversity of OttawaOntarioCanada
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33
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Çoner A, Çiçek D, Akıncı S, Saba T, Müderrisoğlu H. Kaplı Stent Trombozu Sonrası Perikardiyal Kanama: İki Ucu Keskin Bıçak. ACTA MEDICA ALANYA 2018. [DOI: 10.30565/medalanya.421746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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34
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Tajti P, Xenogiannis I, Chavez I, Gössl M, Mooney M, Poulose A, Sorajja P, Traverse J, Wang Y, Burke MN, Brilakis ES. Expecting the unexpected: preventing and managing the consequences of coronary perforations. Expert Rev Cardiovasc Ther 2018; 16:805-814. [DOI: 10.1080/14779072.2018.1533402] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Peter Tajti
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
- Division of Invasive Cardiology, Second Department of Internal Medicine and Cardiology Center, University of Szeged, Szeged, Hungary
| | - Iosif Xenogiannis
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Ivan Chavez
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Mario Gössl
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Michael Mooney
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Anil Poulose
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Paul Sorajja
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Jay Traverse
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Yale Wang
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - M. Nicholas Burke
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
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35
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Shaukat A, Tajti P, Sandoval Y, Stanberry L, Garberich R, Nicholas Burke M, Gössl M, Henry T, Mooney M, Sorajja P, Traverse J, Bradley SM, Brilakis ES. Incidence, predictors, management and outcomes of coronary perforations. Catheter Cardiovasc Interv 2018; 93:48-56. [PMID: 30312992 DOI: 10.1002/ccd.27706] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 05/30/2018] [Indexed: 11/10/2022]
Abstract
OBJECTIVES We examined the contemporary incidence, types, predictors, angiographic characteristics, management and outcomes of coronary perforation. BACKGROUND Coronary perforation is a rare, but important, complication of percutaneous coronary intervention (PCI). There is lack of data on perforations stratified as large and distal vessel perforations. METHODS Retrospective, observational cohort study of all patients who underwent PCI at a high volume, tertiary hospital between the years 2009 and 2016. Angiograms of all coronary perforation cases were reviewed to determine the mechanism, type, and management of perforation. Risk-adjusted periprocedural complication rates were compared between patients with and without coronary perforation. One-year mortality outcomes of patients with large vessel vs. distal vessel perforation were also examined. RESULTS Coronary perforation occurred in 68 of 13,339 PCIs (0.51%) performed during the study period: 51 (75%) were large vessel perforations and 17 (25%) distal vessel perforations. Most (67%) large vessel perforations were due to balloon/stent inflation, whereas most (94%) distal vessel perforations were due to guidewire exit. Patients with coronary perforations had significantly higher risk for periprocedural complications (adjusted odds ratio 7.57; 95% CI: 4.22-13.50; P < 0.001). Only one patient with large vessel perforation required emergency cardiac surgery, yet in-hospital mortality was high with both large vessel (7.8%) and distal vessel (11.8%) perforations. CONCLUSIONS Coronary perforation is an infrequent, but potentially severe PCI complication. Most coronary perforations are large vessel perforations. Although coronary perforations rarely lead to emergency cardiac surgery, both distal vessel and large vessel perforations are associated with high in-hospital mortality, highlighting the importance of prevention.
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Affiliation(s)
- Arslan Shaukat
- Minneapolis Heart Institute, Abbott Northwestern Hospital and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Peter Tajti
- Minneapolis Heart Institute, Abbott Northwestern Hospital and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Yader Sandoval
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Larissa Stanberry
- Minneapolis Heart Institute, Abbott Northwestern Hospital and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Ross Garberich
- Minneapolis Heart Institute, Abbott Northwestern Hospital and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - M Nicholas Burke
- Minneapolis Heart Institute, Abbott Northwestern Hospital and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Mario Gössl
- Minneapolis Heart Institute, Abbott Northwestern Hospital and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Timothy Henry
- Minneapolis Heart Institute, Abbott Northwestern Hospital and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Cedars Sinai Medical Center, Los Angeles, California
| | - Michael Mooney
- Minneapolis Heart Institute, Abbott Northwestern Hospital and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Paul Sorajja
- Minneapolis Heart Institute, Abbott Northwestern Hospital and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Jay Traverse
- Minneapolis Heart Institute, Abbott Northwestern Hospital and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Steven M Bradley
- Minneapolis Heart Institute, Abbott Northwestern Hospital and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Emmanouil S Brilakis
- Minneapolis Heart Institute, Abbott Northwestern Hospital and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
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36
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Kinnaird T, Gallagher S, Cockburn J, Sirker A, Ludman P, de Belder M, Smith E, Anderson R, Strange J, Mamas M, Hildick-Smith D. Procedural Success and Outcomes With Increasing Use of Enabling Strategies for Chronic Total Occlusion Intervention. Circ Cardiovasc Interv 2018; 11:e006436. [DOI: 10.1161/circinterventions.118.006436] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Tim Kinnaird
- Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K., S.G., R.A.)
| | - Sean Gallagher
- Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K., S.G., R.A.)
| | - James Cockburn
- Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (J.C., D.H.-S.)
| | - Alex Sirker
- Department of Cardiology, University College Hospital, London, United Kingdom (A.S.)
| | - Peter Ludman
- Department of Cardiology, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom (P.L.)
| | - Mark de Belder
- Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom (M.d.B.)
| | - Elliot Smith
- Department of Cardiology, St Bartholomew’s Hospital, London, United Kingdom (E.S.)
| | - Richard Anderson
- Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K., S.G., R.A.)
| | - Julian Strange
- Department of Cardiology, Bristol Royal Infirmary, United Kingdom (J.S.)
| | - Mamas Mamas
- Keele Cardiovascular Research Group, Institute of Applied Clinical Sciences, University of Keele, Stoke-on-Trent and Royal Stoke Hospital, University Hospital of North Midlands, United Kingdom (M.M.)
| | - David Hildick-Smith
- Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (J.C., D.H.-S.)
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37
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Divanji P, Shunk K. Complications of chronic total occlusion percutaneous coronary intervention: Subepicardial hematoma. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 19:553-557. [PMID: 29331435 DOI: 10.1016/j.carrev.2017.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 12/22/2017] [Accepted: 12/22/2017] [Indexed: 10/18/2022]
Abstract
A 67-year-old man with coronary artery disease and previous coronary underwent successful Guideliner reverse CART percutaneous coronary intervention of a chronic total occlusion of the right coronary artery. He later developed evidence of myocardial ischemia, and imaging, including angiogram, echocardiogram, and cardiac computed tomography revealing active dye extravasation from the previously normal RV marginal branches, in addition to a large subepicardial hematoma. Despite these dramatic findings, the patient remained hemodynamically stable and pain-free, with resolving ECG changes. Thus, with close clinical observation, the patient did not undergo pericardiocentesis or other invasive procedures, and was discharged home safely. This review evaluates the complications of CTO-PCI, with a focus on subepicardial hematomas, discussing diagnosis and management of this highly morbid complication.
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Affiliation(s)
- Punag Divanji
- Division of Cardiology, University of California, San Francisco, VA Medical Center, San Francisco, CA, United States.
| | - Kendrick Shunk
- Division of Cardiology, University of California, San Francisco, VA Medical Center, San Francisco, CA, United States
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38
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Danek BA, Karatasakis A, Tajti P, Sandoval Y, Karmpaliotis D, Alaswad K, Jaffer F, Yeh RW, Kandzari DE, Lembo NJ, Patel MP, Mahmud E, Choi JW, Doing AH, Lombardi WL, Wyman RM, Toma C, Garcia S, Moses JW, Kirtane AJ, Hatem R, Ali ZA, Parikh M, Karacsonyi J, Rangan BV, Khalili H, Burke MN, Banerjee S, Brilakis ES. Incidence, Treatment, and Outcomes of Coronary Perforation During Chronic Total Occlusion Percutaneous Coronary Intervention. Am J Cardiol 2017; 120:1285-1292. [PMID: 28826896 DOI: 10.1016/j.amjcard.2017.07.010] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 06/26/2017] [Accepted: 07/07/2017] [Indexed: 01/12/2023]
Abstract
Coronary perforation is a potential complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We analyzed 2,097 CTO PCIs performed in 2,049 patients from 2012 to 2017. Patient age was 65 ± 10 years, 85% were men, and 36% had prior coronary artery bypass graft surgery. Technical and procedural success were 88% and 87%, respectively. A major periprocedural adverse cardiovascular event occurred in 2.6%. Coronary perforation occurred in 85 patients (4.1%); The frequency of Ellis class 1, 2, and 3 perforations was 21%, 26%, and 52%, respectively. Perforation occurred more frequently in older patients and those with previous coronary artery bypass graft surgery (61% vs 35%, p < 0.001). Cases with perforation were angiographically more complex (Multicenter CTO Registry in Japan score 3.0 ± 1.2 vs 2.5 ± 1.3, p < 0.001). Twelve patients (14%) with perforation experienced tamponade requiring pericardiocentesis. Patient age, previous PCI, right coronary artery target CTO, blunt or no stump, use of antegrade dissection re-entry, and the retrograde approach were associated with perforation. Adjusted odds ratio for periprocedural major periprocedural adverse cardiovascular events among patients with perforation was 15.04 (95% confidence interval 7.35 to 30.18). In conclusion, perforation occurs relatively infrequently in contemporary CTO PCI performed by experienced operators and is associated with baseline patient characteristics and angiographic complexity necessitating use of advanced crossing techniques. In most cases, perforations do not result in tamponade requiring pericardiocentesis, but they are associated with reduced technical and procedural success, higher periprocedural major adverse events, and reduced procedural efficiency.
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39
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Sandoval Y, Brilakis ES. Preventing and treating coronary perforations: Lessons from disaster management. Catheter Cardiovasc Interv 2017; 89:973-975. [PMID: 28488413 DOI: 10.1002/ccd.27089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 03/29/2017] [Indexed: 11/08/2022]
Abstract
Coronary artery perforations (CAP) are rare in patients undergoing routine PCI with recent contemporary databases reporting an incidence ∼0.3%. Older age, cardiomyopathy or left ventricular dysfunction, mechanical circulatory support prior to PCI, and CTO lesions have the strongest association with CAP. Prevention, early detection, preparedness and familiarity with the equipment used to treat perforations (such as efficient use of covered stents, and fat or coil embolization) and regrouping to examine and educate about these experiences are key for improving our response to cath lab disasters.
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Affiliation(s)
- Yader Sandoval
- Division of Cardiology, Hennepin County Medical Center, Minneapolis, Minnesota.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
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